How To Diagnose And Treat A Big Toe Injury

The big toe might be a small joint, but that doesn’t mean it isn’t important for runners. It serves a critical function in creating more leverage to generate forward momentum when you run, and because of this, it is susceptible to several overuse injuries.

Among runners, a big toe injury is not common. Even with a very generous definition that includes all toe injuries and injuries to the “sole” of the foot, this accounts for less than five percent of all running injuries according to one study.1

Another study published in 2002 found that none of the injuries that affect the big toe were among the top ten most common running injuries.2 For more on common running injuries please read Common Running Injuries.

Despite this, an injury to your big toe can set you back for weeks or months if you can’t diagnose it. Even though it’s very small, the big toe joint (known to medical professionals as the metatarsophalangeal joint has several distinct anatomic components, each of which is susceptible to injury.

The Mystery The Big Toe Joint

There’s a lot more going on inside your big toe joint than just two bones articulating. Because it handles so much force during walking and running, the joint has special adaptations to create additional mechanical leverage. One of these is the presence of tiny bones called sesamoids (a word that has the same root as “sesame seed,” because these bones are so small).

These function just like your kneecap. They create a mechanical advantage to multiply your force. However, the downside of this is that the sesamoids, alongside the ligaments and tendons that surround them, are vulnerable to injury.

Partially because of the rarity of big toe injuries, we don’t know a whole lot about the risk factors for them, or what kind of runners get them.

From basic biomechanical principles, we can predict that forefoot strikers and middle-distance runners may be more likely to get big toe injuries, because of the increased demands these runners place on their big toe joint.

Older runners may be at greater risk of big toe injuries too, because as we are about to see, some big toe injuries are related to chronic degenerative changes in the joint that accumulate over many years of wear and tear.

How To Diagnose And Treat A Big Toe Injury In Runners

When pain in your big toe prevents you from being able to run, the first order of business is to get a solid diagnosis. Big toe pain isn’t like Achilles tendon pain, where it’s pretty easy and obvious what the problem is.

There’s a multitude of possible causes for your pain. It could be hallux rigidus, turf toe, sesamoiditis, or tendonitis of the flexor hallucis longus tendon. All of these can cause big toe pain while running.3

Hallux rigidus is a term for a form of degenerative arthritis of the big toe joint. As you might guess from the name, one of the defining characteristics is a persistently “rigid” or stiff big toe joint. Your range of motion will be limited, and you’ll likely find walking barefoot to be more painful than walking with shoes on. You might have some swelling, too, but you won’t have any bruising. Fortunately, it’s easy for a doctor to definitively diagnose hallux rigidus and evaluate its severity with a plain x-ray. The downside is that, because it’s a degenerative condition, treatment is mostly focused on reducing stress on the joint through orthotics or shoe modifications, plus anti-inflammatories to reduce swelling. In more advanced cases, surgery is sometimes needed to cut out the bone spurs that develop in the joint as the cartilage wears away.

Hallux valgus is the medical term for a bunion, which is probably the easiest big toe injury to diagnose. If you have pain on the side of your big toe joint, and your big toe is angled inwards, you can almost assuredly chalk it up to having a bunion. Initially, if the angle at which your big toe is pointing inwards is not too bad, you can get by with modifying your running shoes to take pressure off the outside of your foot. Some runners just take a razor blade to the shoe upper and cut a slit to reduce pressure on the side of the big toe, but buying a shoe with a roomier toe box can also work.

Turf toe is one of the most common causes of big toe pain in athletes. Though it happens more commonly in football and soccer players, it does affect runners, too. You can think of it as the big toe equivalent of an ankle sprain: hyperextension of the joint causes damage to the ligaments that surround the big toe, and the result is substantial swelling, bruising, and severe pain when you try to walk. The ligaments need time to heal, so treatment for turf toe involves icing, rest, and using an air-cast or a similar device to immobilize the joint while it heals. It is a good idea to see a doctor for this one, because many medical professionals recommend placing the big toe joint in a specific position while it’s immobilized, to ensure that the ligaments don’t stay hyperextended when they heal.

A violent hyperextension of the big toe, as pictured here, can cause turf toe

Once you gradually return to running after turf toe, you can use a turf toe taping to reduce stress on the area. This taping limits the ability of the big toe to go into hyperextension, so it’s a good insurance policy when you are first starting back up.

What Is Sesamoiditis

Sesamoiditis is an inflammation of the sesamoid bones. And is characterized by pain localized directly over the ball of your foot. Pain is more strongly associated with direct pressure on the ball of the foot than with flexing or extending the big toe.

You can usually reproduce the pain by simply pushing directly on the ball of your foot with your thumb. Sesamoiditis will hurt more when walking barefoot, especially on hard surfaces.

Treating sesamoiditis involves reducing stress on the ball of your foot, hopefully to the point where the stress of running doesn’t aggravate it anymore. Rest will help, but you can also modify a standard over-the-counter orthotic with felt padding or get a custom orthotic with a divot underneath the ball of your foot.

Do keep in mind that, while this will decrease stress on the ball of your foot, it will increase stress on the rest of your forefoot, so use this method judiciously. Beyond this, there are no special exercises or anything you can do for sesamoiditis; just the same old rest and icing routine.

Stress Fracture In The Sesamoid

In some cases, ball of foot pain might not be just sesamoiditis, but a stress fracture in the sesamoid. The pain from a stress fracture will be more severe, and might limit your ability to walk at all when barefoot. The best way to diagnose a stress fracture is with an MRI, though some doctors will look at plain x-rays for evidence.

This can cause some false positives, though, since up to one-third of the population has “bipartite” sesamoids, meaning one or more of their sesamoid bones is naturally parted in two, and can be mistaken for a fractured sesamoid.4

Sesamoid stress fractures have a high risk of poor healing, so you’ll need to be in a boot, cast, or modified orthotic for at least several weeks to ensure that it heals properly.5

Flexor Hallucis Tendonitis

Finally, pain in the big toe might be due to flexor hallucis tendonitis (FHL), for short, is a tendon that helps flex your big toe downward and helps you push off the ground when you run. Because it runs underneath the sesamoids and attaches to the big toe, it can cause pain in the joint or along the arch of your foot.

In some cases, it might even be mistaken for plantar fasciitis. FHL tendonitis will cause pain that extends into the arch of your foot, and is worst when you push off the ground.

It’s worth noting that FHL tendonitis is rare to begin with, and is rarer still in the region of the tendon that passes under the big toe joint. The good news is that, as a tendon injury, it should be amenable to stretching and strengthening exercises.

A 2005 paper by Doctors James Michaelson and Laura Dunn suggest three specific stretching exercises for the FHL to be done several times daily for ten seconds each. These three stretches, all variants of ordinary calf stretches, are designed to put controlled tension on the FHL.

The authors report good outcomes in a large number of patients from this routine alone, though some did need surgery.6

The three calf stretches proposed by Michaelson and Dunn. Do these several times daily for 10 seconds each to treat FHL tendonitis.

A 2015 paper by researchers in Japan and California suggests adding calf raises with the toes hanging off a step as a rehab exercise.

The goal here is not to strengthen the FHL; rather, the goal is to take stress off it by training the body to use other muscles to plantarflex the ankle.7

No specifics are given by the authors, but a good place to start would be 15 single leg calf raises with the toes off a step every day, increasing over time to three sets of 15.

It may not be easy to pinpoint the problem. If this is the case, see a trusted doctor, because you might need X-rays or, more rarely, an MRI, to definitely diagnose the problem.

The correct treatment is going to largely depend on what the problem is. Unfortunately, most big toe injuries need a lot of time off from running, and may even need to be immobilized in a cast to heal properly.

In all cases of big toe injury, the primary solutions are to 1) allow the damaged area to heal or allow inflammation to subside and 2) reduce stress on the big toe.

Return to running is also going to depend somewhat on the specific injury that’s causing your big toe pain, but sadly, most require several weeks or even months off from running.

Check with a doctor or physical therapist if you’re unsure about whether you’re ready to run again, because some big toe injuries, like turf toe and sesamoid stress fractures, need to be totally healed before you try to run on them again.